Insurance Review Pending…

Link to the game: https://nfakih.itch.io/insurance-review

Overview

A new branch of Better US insurance opens in your area and you are hired as Insurance Claim Reviewer. Without your rubber stamp of approval, no one will get health care. The game will commence in three stages.

Stage 1:

Everyday you come into your office and check your mail for memos from the company and news updates that may affect your review process. You then proceed to approve or deny cases based on their healthcare plan level of coverage.

Stage 2:

You are sent to speak to a patient’s family on the behalf of Better US.

Stage 3:

You return to Better US, changed by your experiences.

Insurance Review Pending… attempts to highlight the intersectionality between trans healthcare, reproductive rights, gender-affirming care, and seeking care in poverty by illustrating the lack of bodily autonomy all those parties have in our current healthcare system. All cases and their approval/denials are based on real life experiences from Queer people I have interviewed.

The first stage is for the player to learn and listen while they unknowingly become complicit in the death of patients. Through the cases, newspapers, memos and appeals, the player will learn different reasons certain treatments/medications are prescribed and how they are rejected by insurance companies due to company or government policies.

The second stage is to humanize the patient who died and where the real interactive fiction begins. The player will attend the patient’s funeral and learn about them by having conversations with the attendees.

The third stage is when the player returns to Better US and is forced to combine the logic of stage 1 with the emotion of stage 2. The cases stop being factual and the player begins to see personal information about each patient. They are unable to because our current healthcare system does not allow room for care.

Playtests & Iterations

Initial Concept & Playable Prototype 0

My initial concept focused on gender-affirming care and followed a very different premise. My true goal for my dystopian interactive fiction was to highlight how gender-affirming care is just a part of regular, necessary health care for people unfamiliar with the Queer community. Playtesting revealed that my initial concept started off blatantly biased and playtesters who were uncomfortable with LGBTQ+ centered topics or hold misinformation are not allowed to enter the magic circle. Read more about that experience here.

I was inspired by Eric Curts’ post about Dragon Quest which is made in Google slides by hyperlinking texts to slides. My initial prototype: https://docs.google.com/presentation/d/1QQ8ngyOmaaUm5AxLtFq4sal5PBGOjUU9FJestBYVYX0/edit?usp=sharing

Playtesters

1 male, White, Cisgender, in-class

1 male, White, Cisgender

1 female, Asian, Cisgender

1 female, Latino, Transgender

Although I have gone through many small iterations in between playtests, there were 3 major versions of Insurance Review Pending.

Playtest Prototype 1

My concept went from rogue Queer hacker vs an anti-gender affirming care government to an insurance reviewer trying to live with themselves for denying people life-saving care. I wanted the world to highlight our lack of bodily autonomy due to our dystopian health care system. This reminded me of the premise of Papers, Please, so I decided to mod it and make my interactive fiction include visual elements such as patient cases. I thought this would help me make the game easier to connect to.

The game only included newspapers to mark the change of days and policies, and the patient cases that had to be reviewed each day.

The playtesters all agreed on the same thing, the current structure of the game was too logical and they did not believe tweaks to the cases could make up for all the missing emotion. They proposed the following solutions which I adopted:

Change the faceless icons on the cases to ones with character and expression
Add “appeals” after each day to get injections of humanity
Add a repeating character whose case keeps getting rejected. Then have the player pass and follow that emotional journey.

Players enjoyed the visual elements of the newspaper and cases.

Playtesters

1 male, Asian, Cisgender, in-class

1 non-binary, Indian, Transgender

1 female, Asian, Transgender

1 non-binary, Latino, Transgender

1 non-binary, Asian, Transgender

Playtest Prototype 2

In the next iteration, the game has two phases: the logical phase where you approve/deny cases and the second phase where you go to the funeral of the patient who died. Playtesting revealed that players really enjoyed the twist of having one of their patients pass and the function of the newspaper.

Players really enjoyed the structure and polish of the logical stage with different fonts and templates clearly signaling who the message is from.

Playtesters

1 female, Asian, Cisgender, in-class

1 male, White, Transgender

1 non-binary, Asian, Transgender

1 non-binary, Black, Transgender

Final Prototype

In the final prototype, I implemented a third stage where the player returns to the insurance company and attempts to reconcile with the fact they are a part of a system that does not inherently care for people. The playtesters who played previous iterations of the game felt satisfied and excited by the third stage and final result. They really appreciated the use of changing the background to indicate different tones and emotions, such as red for the funeral speaker when they’re outraged, blue for their story about the duckies, and white as a default.

They also noted a deep love for the blur elements that obscure the player’s internal thoughts.

The subtle change in the link here.

And varying font sizes

In the end, the patient who died was also the same one who filed an appeal for puberty blocker ban to be reconsidered and to urge Better US to not participate in further lobbying. They work for the SF LGBTQ+ Center and their funeral was held there as well where they meet family, friends and the community members that they have touched. They return to Better US and learn all the people they accidentally approved were denied ultimately and that no matter what their choices were, Leila would have still passed. They also learn Better US sent you over as an attempt to prevent a lawsuit from happening. You return to your work but can not just see facts. You begin to see the humanity of every case.

You quit Better US and begin volunteering at the SF LGBT Center in Leila’s memory.

Future Work

Insurance Review Pending accomplishes nearly all my goals. All playtesters left the final playtest feeling as if they learned so much about Queer healthcare without even noticing. They loved the three phases and their complicity in Leila’s death. Most of all, they loved that in the end hopelessness did not win, and that humanity prevailed with the player going to the LGBT Center.

I plan to continue working on Insurance Pending Review… and implement the following improvements:

Increase quality consistency of cases
Change the newspaper spam text to something less distracting
Plan out other branches where the player can meet and interact with different people who knew Leila at the Center
Polish the information about the center and the puberty blocker ban
Change the end screen to include resources to learn more and to donate to the LGBT center.

Reflection

Making Insurance Review Pending… was a journey. I found myself diving deep into Queer healthcare and gender-affirming care only to have the story somehow come back to me. The more I looked into gender-affirming care, the more I came back to the conclusion that our true pitfall is lack of bodily autonomy and a universal health care system. I didn’t mean to write myself into the story but as my playtesters demanded a regular patient who repeatedly got denied for a worsening condition, I put my own journey as a poor person navigating healthcare and a worsening chronic condition as a placeholder. There is something really cathartic about putting your frustrations into a video game and personifying insurance so you can scream at them.

Although Leila’s medical journey mirrors my own, her name is inspired by my late Tata Leila (الله يرحمة) who passed away from stage IV lung cancer in December 2020. She too was failed by the medical system because she was constantly denied access to care and by the time she was treated, her cancer had already progressed to stage IV. It’s also cathartic to create an insurance person that gets yelled at by the people they have been denying. My playtesters who faced similar challenges agree.

I am extremely interested in building out branches, but I am very happy with the core story and the game as it is. It definitely needs some polish with the graphics and text but I got amazing feedback from my final playtesters.

I went to a Queer gathering on Friday, November 3rd and passed the game around. No one was allowed to talk about the game until everyone present had a good. Then the feedback session began, here are some quotes:

“It’s giving neo-dada, it’s an art movement where things that didn’t make sense became art” – referencing the newspaper

“This tells you its people doing this in the insurance company… it’s people.”

My favorite comment was when someone said that the sister shouldn’t have forgiven the player. They erupted into debate and came to the conclusion that

“They just got radicalized! They should be forgiven at some point. They should be allowed to change and move on from who they used to be… otherwise… what’s point? We all changed our minds at some point, we all used to be complicit… “

Credits

Structure of Phase 1

Mod of Papers, Please

Thank you <3 to

Lois, Fran, Phillip, Alex, Reyan, Silver, Opal

Articles

Debunking myths about puberty blockers for transgender children – Pharma Technology Focus | Issue 98 | September 2020

Puberty blockers and side effects: How to think about the controversy.

Video Essays

What Studies Say About Transgender, Gender Dysphoria, and Gender Affirming Care by Doctor Youn

Gender affirming care from the viewpoint of a US Medical Physician

I Emailed My Doctor 133 Times: The Crisis In the British Healthcare System by Philosophy Tube